URINARY TRACT INFECTION P R O T O C O L

URINARY TRACT INFECTION

P R O T O C O L BY

AHMED SOLIMAN ABDELHALIM SOLIMAN ,MDLECTURER OF PEDIATRICS

PEDIATRIC NEPHROLOGY &DIALYSIS UNITBENHA UNIVERISITY

EL HADA ARMED FORCES HOSPITAL ,TAIF, KSA(LAST UPDATE NOVEMBER 2014)

BASICS INTRODUCTION • It Is A Potential Serious Infection• The Highest Incidence In The First

Year Of Life• It May Be Pyelonephritis Or

Cystitis • The Commonest Error In The

Management Of UTI In Children, And Especially In Infants, Is Failure To Establish Is The Diagnosis

• Escherichia coli remains the predominant uropathogen.

• Other organisms such as klebsiella , proteus and enterobacter species , staphylococci, and Streptococcus faecalis , GBS.

• Hematogenous spread is common in

newborns and infants in contrast to ascending infection in older children

BASICS Organisms

E.COLI VIRULENCE FACTORS

BASICS DEFINITIONS (CLASSFICATION)

CLINICAL APPROACH OF

UTI

STEP 1 : HOW TO SUSPECT UTI ?

STEP2: HOW TO DIAGNOSE UTI (CULTURE)?

STEP 3 : IDENTIFY THE SITE OF UTI

STEP 4 : ANTIBIOTIC THERAPY FOR UTI

STEP 5 : WHAT IS THE UNDERLYING PATHOLOGY ?

STEP6: FOLLOW UP FOR RECURRENCE ?

CLINICAL UTI APPROACHO C T O B E R 2 0 1 3

NICE guidelines recommend the testing of urine in infants and children with: • Symptoms and signs of UTI. • Unexplained fever of 38 ° C or higher • An alternative site of infection but who remain unwell .

STEP (1 ) :How to suspect UTI? O C T O B E R 2 0 1 3

The gold standard for diagnosis of UTI is the urine culture.

Tests That Help Improve the Predictive Value of UTI • Presence of >10 white blood (HPF)

(77%,89%)• Nitrate reductase test (50%,98%)• Leukocyte esterase test (84% ,78%) • The combination of leukocyte esterase

and nitrite tests(72%,96%)

STEP 2:Diagnosis

NICE recommended techniques • Catheter sample or suprapubic aspiration (SPA),

• method of choice in the severely ill infant under 1 year,

• requiring urgent diagnosis and treatment, and in cases where

Alternatives (not NICE recommended) An adhesive plastic bag (screening test). midstream sample.

STEP2 : Diagnosis

STEP3 :IDENTIFY SITE

• Abdominal us (not sensitive)• DMSA (most senstive)• CT with contrast (risky)• MRI with contrast

(expensive)

DMSA

CT (contrast)

MRI (contrast)

• Age • Pyleonephritis or cystitis • General conditions • Choice of antibiotics • Doses of antibiotics .

STEP 4:Treatment

Below 3 months of age

Start parentral antibiotics for 2-4 days then oral for

10 days

Above 3 months of age

Pyleonephritis Cystitis

start oral antibiotics for 7

days unless vomiting Start

parentral antibiotics for 2-4 days then oral for

10 days Oral antibiotics for 3

days

NICE guidelines regarding antibiotic treatment 2007 are as follows

Treatment

Step 5 :Identify underlying pathology

Role out obstructive uropathy especially VUR

Recurrent UTI

Two attacks in less than 6 monthsRecurrence is seen in 30–50 % The risk factors for recurrent UTI

• Girls • Age <6 months • Phimosis/labial adhesions • Obstructive uropathy • Voiding dysfunction • Constipation • High-grade vesico-ureteral reflux

(VUR)

Recurrent UTI : VUR

Recurrent UTIChemoprophylaxis “AAP 2013”

Recurrent without VUR

Recurrent with VUR

evidence that prophylactic antibiotics prevent recurrent

UTI in children without VUR is weak.

• Antibiotic prophylaxis may not be warranted in children with low-grade (grade I–II) VUR.

• antibiotic prophylaxis may have a role in grade III–V VUR, especially in children <5 years of age

Recurrent UTIChemoprophylaxis choice

BENHA UNIVERISITY BENHA UNIVERISITY HOSPITALS

PEDIATRIC NEPHROLOGY & DIALYSIS UNIT